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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602414
Report Date: 01/31/2022
Date Signed: 01/31/2022 05:52:46 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20211228164114
FACILITY NAME:BROOKDALE NORTH TARZANAFACILITY NUMBER:
197602414
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(818) 996-2022
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:135CENSUS: DATE:
01/31/2022
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Dana AndersonTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
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9
Staff yelled at resident.
INVESTIGATION FINDINGS:
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2
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9
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12
13
Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Dana Anderson, Executive Director (ED). The purpose of the visit was discussed.

--- Staff yelled at resident.

It was alleged that the resident made a comment to the driver for being late and the driver yelled at him. To investigate this allegation, on 01/04/2022 at 10:00am, LPA interviewed staff and residents. Interviews and record review revealed that on 12/27/2021 Resident #1 (R1) had a verbal exchange with multiple staff members, however, the exchange between R1 and the facility’s driver was not witnessed. Interviews with both residents and staff further revealed that they have neither witnessed or experienced staff yelling at residents. During the interviews, all residents stated that they are being treated well.
Based on interviews and record review, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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